Chapter 11

BACKGROUND AND STUDY SETTING

INTRODUG'b10N

This chapter presents the rationale for selection of a public hospital setting

for the study. This is followed by a brief description of the salient features

of the hospital that are of relevance to this study.

2.1: Rafionade and Significance of the Study:

Non-profit sector: While quality has become a more accepted,

researched and implemented concept in the private and for-profit health

care sector, in lndia the non-profit sector needs more attention as it

serves a very large population under conditions of very scarce

resources. Through a search of standard databases and survey of

literature of indexed Journals, it was found that reporting from lndia was

extremely inadequate. Another report of a WHO SEAR0 Region study

of 35 countries confirms this situation of developing countries in Asia as

a whole including India. (Amala de Silva, 2000).

0 Beneficiary perceptions: Programs for internal quality audit of hospital

services in the form of Medical Care Reviews analyze clinical

processes and outcomes for taking corrective measures. Hospitals

regularly conduct for their own internal consumption, quality initiatives

related to clinical processes and outcomes, like measuring hospital

mortality rates, infection rates, prescription adequacy, follow-up and

compliance rates, readmission rates and clinical care reviews.

Assessing hospital performance quality with reference to inputs - financial, human resource, skills, materials, drugs, and equipment - is

done for the purpose of deciding future allocations. Measures of

attainment of targets in terms of the promotive, preventive, curative,

and rehabilitative role expectations from public hospitals, are also

regularly undertaken and widely reported as inputs to policy

formulation.

However, beneficiary assessment studies in terms of dimensions of

service quality from the point of view of external customers (clientele)

and internal customers (employees) has not been attempted in the

public sector in India. Some private corporate hospitals routinely get an

exit pro-forma filled up by their customers and I or maintain a

suggestion box system to gather feedback.

Services marketing oppoatunity: This study was designed to

understand the dimensions of service quality to facilitate application of

the services marketing triangle of internal, external and interactive

marketing to better utilize the resources, provide the basis to build

accountability and transparency from the service providers and

participation, involvement and responsibility from the customers.

0 Profile of clientele: The education, income and awareness levels of

the clientele being predominantly of the lower level, the methodological

issues in understanding their perceptions of service quality and

expectations from a health care service provider needed to be

addressed.

Strengths / Weaknesses analysis: Being a hospital in the government

sector poses attendant challenges in the areas of pricing, social cost-

benefit analysis and expectations. Services are either free of charge or

heavily subsidized and the challenge lies in how to make the providers

and clientele more responsible in facilities use. This framework is quite

unlike that of private or corporate hospitals where high revenue

services can be maximized and low yield services withdrawn or

reduced. This study identifies those weaknesses of a public hospital

that can be addressed and reduced by the use of better management

practices. The study also presents the strengths of a public sector

teaching hospital that can be leveraged for pricing decisions in future.

Demand patterns: As against a limited available facility, public

hospitals face a peculiar demand pattern of catering to a multitude of

patients on the one hand and a range of medical conditions spanning

extremely minor ailments to those requiring super-specialty care putting

the employees and facilities under great pressure. This condition is true

regardless of whether the hospital has been conceived to function at

the primary care, first level referral, secondary referral, or tertiary

referral level. A study of the implications on service quality as perceived

by the customers can be a useful input for assessing infra-structural

requirements, job design and training of various levels of employees.

Patients' Charters: A study of this nature can provide inputs to drafting

and implementation of Patients' Charters as a pro-active measure in

order to fulfil present and future expectations of customers.

e Provider-patient inequality: Such a study can positively influence the

re-designation of a patient as a customer or client, lending more

equality to the provider-patient dyad. The perception of unequal power

relations is particularly true of government hospitals, as the services are

free or very nominally priced.

Organizational culture and governance: In addition to the customers'

perspective, a study of the organizational setting and service culture

can provide inputs for a re-think on the policies of governance of a

public sector hospital.

2.2: THE RESEARCH SETTlNG

This study was conducted in the Jawaharlal Institute of Postgraduate

Medical Education and Research (JIPMER) Hospital, a tertiary care public

teaching hospital and medical research institute operated directly under

the Directorate General of Health Services, Ministry of Health and Family

Welfare, Government of India. JIPMER, located in Pondicherry in South

India, is internationally acclaimed for the quality of its under-graduate and

post-graduate medical education programs and consistently ranks among

the top five institutions in the country.

s Key respondents: This study has sought to bring to light the service

quality expectations and perceptions of customers of this public sector

teaching hospital from the point of view of its external customers - in-

patients, and key internal customers - consultant doctors and nursing

personnel.

0 Customer locations: Being a centrally administered referral hospital in

South India, the clientele or patients seeking treatment are drawn from

all the southern states of India, predominantly from Pondicherry Union

Territory and the neighbouring state of Tamil Nadu.

0 Prohibition of Private Practice: As against the hospitals run by the

various State Governments, Central Government Hospitals preclude

private practice and hence quality perceptions can be solely attributable

to the service experience within the hospital setting for the entire range

of services availed. This service condition applies for the employees of

JIPMER and hence customer perceptions are uninfluenced by the

private practice component. Consequently, findings and suggestions

emerging from the study can be more actionable and useful as it

reduces the need to shift from the generic theory to the specific

application.

Teaching and Research affiliation: As compared to any Government

Hospital per se, JIPMER Hospital is attached to a teaching and

research institution. While these components may contribute to the

quality of care, it must also be noted that the time of the employees

gets divided between fulfilling teaching, training and research

obligations and providing patient care. Other teaching hospitals in

similar contexts could draw valuable lessons from the findings.

* Generalimtion: This study can be replicated with minimal

modifications to the other centrally administered public sector hospitals

in the country. Fufiher, it can give more impetus to increasing

accountability and transparency from all the stakeholders involved in

the system.

A brief overview of the hospital and patient care related activities of the

institute would provide fuller justification for the choice of JlPMER as the

location for the study. The following section provides only details of patient

related aspects and does not cover medical education and research

activities.

2.3: JIPMER - A PROFILE OF HOSPlTA L AND PA TIENT CARE

This section has been prepared by selecting the relevant information from

the Hospital Records, JlPMER Handbook, and web-site www.jipmer.edu

2.3.1 : Historical Background

e Medical school 'Ecole de Medicine de Pondichery' under the French

Government, established in 1823.

Taken over by Government of India with 'de jure' transfer of

Pondicherry, in 1956.

e College building inaugurated and named 'Jawarharlal Institute of

Postgraduate Medical Education and Research', July 1964.

JlPMER Hospital started functioning from April 7966.

2.3.2: Departments

Clinical services: Anaesthesiology, Dental Surgery, Dermatology, E.N.T,

General Medicine, General Surgery, Neurology, Obstetrics

& Gynaecology, Ophthalmology, Orthopaedic Surgery,

Paediatrics, Psychiatry, Preventive & Social Medicine,

Radio-diagnosis & Radiotherapy, Tuberculosis &

Respiratory Diseases.

Super-speciality Services: Cardiology, Cardio-thoracic Surgery, Plastic

Surgery, and Urology.

Clinical Suppopt Services: Biochemistry, Blood Bank, Microbiology,

Pharmacy, Pathology, Physiotherapy, and Radiology.

Nursing Services: Assistant Nursing Superintendents, Nursing Tutors,

Nursing Sisters and Staff Nurses to provide Emergency,

Intensive Care, and Routine Nursing services.

Auxiliary Services: Central Sterile Supplies (CSSD), Kitchen, Laundry,

Medical Records (MRD), Sanitation, Waste Management.

Peripheral Services: Urban and Rural Health Centres, Mobile Health Clinics,

Mobile Operation Theatre.

2.3.3: Pa tien t Care Services Profile In addition to regular outpatient and inpatient services, JIPMER hospital

offers the following services:

Emergency Medical Care: Twenty-four hour services in a separate

Casualty Block, headed by a Casualty Medical Officer, functions on all

days, and is equipped with an emergency operation theatre. Resident

doctors and Duty doctors are available 24 hours, and Consultants are

available on call as and when required.

lntensive Care: Medical, surgical, and respiratory critical intensive care

units provide critical care services for cases of heart attack, poisoning,

stroke, etc. The hospital maintains fully equipped medical (MICU), surgical

(SICU), cardiac (CICU), and paediatric (PICU) intensive care units.

Super-speciality Care: The super speciality departments provide open

heart surgery for replacement of valves, by pass of coronary arteries

(Cardiothoracic surgery), genito urinary surgery (Urology), and the Plastic

surgery department runs a Burns unit. Breast Cancer screening & Surgical

Gastroentrology clinics, Video Laproscopic surgery and Nasal Endoscopic

Sinus surgery services were added in the recent past. The Orthopaedic

centre houses modern facilities with physiotherapy and occupational

therapy units. Cobalt teletherapy and brachytherapy units are available in

the department of Radiotherapy. Department of Cardiology is equipped

with a sophisticated 'Cardiac Cath Laboratory' and specializing in non-

surgical management of heart diseases. It is emerging as a number one

centre for implantation of 'pace makers'.

2.3.4: National Health Programs

9 Family planning, Leprosy Eradication, Malaria control, Prevention of

Blindness, ICDS, Control of AIDS, Expanded program of immunization.

0 The department of Psychiatry is recognized as one of the five National

Drug De-addiction Centres in the country.

Q The department of Microbiology is recognized as a Centre for Sero-

surveillance of HIV Infections and Viral Hepatitis.

Q AFP surveillance is conducted by department of Paediatrics, which is

also equipped with a Neonatology Unit.

Q The department of Pharmacology runs one of the six Adverse Drug

Reaction Monitoring Centres in the country and recently a Sleep

Laboratory has been set up to study sleep disorders.

2.3.5: Citizens' Charter The hospital has drawn up a Citizens' Charter containing all information

about the following: General Information, Profile of Services including

Outpatient, Inpatient, Emergency, and Intensive Care, Possible Service

Standards, Service Timings, Special Clinics, Equipment and facilities,

- - - - - -- - - - -

Amenities for patients and atiendants, Complaints Redressal Procedure,

Mortuary Services, and finally, the Responsibilities of the User. (The text of

the Citizens' Charter is presented as an Annexure).

2.3.6: Hospital Bed Strength: Total In-patient Beds = 860.

Medicine 129

Cardiology 20

List A

1 Neurology 12

k k t B*

1 Dermatology 39

Surgery

Urology

Plastic Surgery 18

Orthopaedic Surgery 58

Ophthalmology 37

E.N.T. 30

Psychiatry

T.B. & C.D.

Radiotherapy 8

Paediatrics 69

Cardio Thoracic Surgery 23

Paediatric Surgery 2 5

Casualty

TOTAL

NOTE:

1 Dental 4 / 'Separate lists have been drawn up to 1 Obstetrics & Gynaecology 1 10

(incl. Post Partum)

Special Wards 65

indicate that patients of these

departments are not included in this

study. The hospital makes no such

division.

[ TOTAL 667 Source: JlPMER Handbook, 1 999

2.3.7: Key Hospital Statistics - 2000 Trends:

Considering the year 1998 as the base, the strength of

Outpatients treated has shown an increase of 4.71 percent. The

number of Inpatients served by the hospital has shown an

increase of 19.04 percent. Data regarding geographical

distribution of inpatients sewed by the JlPMER hospital reveal

that about 78.5 percent of the users come from states outside

Pondicherry, although a major share of this group belongs to the

neighbouring state of Tamil Nadu. The 21.5 percent of patients

from Pondicherry who have used the services of the hospital,

also includes the employees and their dependents.

The hospital outpatient department attracts more than 4000 patients daily

not only from Pondicherry but also from the surrounding states of

Tamilnadu, Andhra Pradesh, Karnataka and Kerala. The inpatient

departments have 860 beds distributed among various medical, surgical

and super specialities. [Note: All figures are in Thousands]

Outpatients: 1277.078

Out-Patient New Cases : Pondicherry - 48.777, Others - 178.521

Casualty Attendance : 107.7

Bed Occupancy Rate: 1 17.3

Operations performed : 45.06 Deliveries: 9.41 6

Laboratory Investigations: Biochemistry: 773.593

Microbiology: 77.665

Pathology: 123.024

The following graphs and tables show the trends of patients' usage of the

hospital's services. In the tables showing outpatients and inpatients

served, the percentage change has been calculated using the year 1998

as the base in order to give an indication of usage. It must be noted that

during the three-year period there has not been a corresponding

enhancement of infrastructure and other resources. The geographical

distribution of patients has been presented over a period of twenty years

i.e., 1978, 1988, and 1998.

--

Figure 2.3a: Trend of Outpatients at JlPMER

Source: Hospital Records

atients

Table 2.3a: Trend of Outpatients at JlPMER

Source: Hospital Records

increase (%) (base year '97) I Year

Outpatients (number)

Figure 2.3b: Trend ~f Inpatients at JIPMER

Source: Hospital Records

Table 2.3b: Trend of inpatients at JlPMER

Year

1997

1998

1999

2000

Inpatients (number)

increase (%) (base year '97)

Source: Hospital Records

37,741

38,504

41,394

44,925

763 (2.02)

3,653 (9.68)

7,184 (1 9.04)

Figure 2 . 3 ~ : Outpatients New Cases Geographical Distribution

200000

150000

a OOOOO

50000

0

L J

Source: Hospital Records

Table 2 .3~ : Outpatients New Cases Geographical Distribution

Source: Hospital Records

Total Year Pondicherry Other States

2.4: ORGANIZATIONAL S'bRUG'6URE Figure 2.4: P a ~ i a l Organizational Chart

MEDICAL SUPERINTENDENT Hospital Sewices

CONSULTANTS CHIEF NURSING / / MEDICAL OFFICERS 1 Edn. & Hosp. Serv.

A I CASUALTY ' 1 I

/ SENIOR RESIDENTS / 1 1 / CLINICAL SUPPORT SERV I P.G. RESIDENTS NON P.G. RESIDENTS 1 ' I ' / AUXILIARY SERVICES

I

DEPUTY NURSING SUPDT.

I ASST. NURS. SUPDTS. / I NURSING TUTORS I

NURSING SISTERS

Source: Original - constructed for the study

NOTES: 1. Consultants hold teaching designations - Director Professor, Professor, Associate

Professor, and Assistant Professor. 2. Resident Doctors under the supervision of consultants lend medical services and

undergo training. 3. In the nursing hierarchy, Asst. Nursing Superintendents, Nursing Sisters, and Staff

Nurses are the direct caregivers to patients. 4. Medical Officers supervise casualty / emergency, clinical support, auxiliary, and

peripheral services. They manage teams of employees responsible for the respective services i.e., labs, medical records, pharmacy, sanitation, etc.

5. This chart presents only the portion of the hospital structure involved in patient care.

2.5 : HOSPITAL SERVICE PROCESSES Figure 2.5~1: SERVICE PROCESS: Entry As Outpatient

Records Clinic

Admit as inpatient No * L _ _ Y y 1 and Exit

Operation Theatre U u

Post-operative care

u V Outcome

Cured / Relieved Status quo / Worse Death

u u I Referral & Discharge 1 EXIT EXIT EXIT

Source: Original - constructed for the study

NOTES: 1. Medical Records Dept. issues Case Sheets to patients and sends them to

appropriate Outpatient department clinic for getting consultants' services. Waiting time can go up to more than two hours.

2. Patient faces long wait for Lab investigations, X-ray, as prescribed. Advised to return at a later date for result and further consultation.

3. Diagnosed during next visit, given medical and follow-up advice. Collects available medicines free from hospital pharmacy and exits. If needed, admitted as inpatient, if bed available. Sometimes, patient has to make multiple visits for getting a bed.

4. For inpatient, treatment processes are at bedside if patient too ill to move, or guided for investigations if support staff available and willing. Consultants take treatment and training "ward rounds" along with their teams, spending time at patients' bedside as per the medical needs and complexities of the case.

5. Patient given Discharge Summary with follow-up advice, referred to super-speciality care (other public hospitals) if needed, or, in case of death, transferred to mortuary and relatives advised immediately, to takeover within three days.

Figure 2.5b: SERVlCE PROCESS: Entry Yhro. Casualty / Emergency

+ Casualty /Emergency 3

Source: Original - constructed for the study

.v V Yes No

NOTES: 1. Patient who enters the hospital via Casualty or Emergency Services Department is

given first aid as needed and kept under observation in the casualty ward. 2. Transferred to lntensive Care Unit if necessary, Emergency Surgery performed if

necessary, or admitted as inpatient and transferred to inpatient ward. 3. Subsequent processes are as already detailed in the previous figure. 4. While all patients are able to recall their outpatient service experience in the hospital,

most patients are not able to recount their experiences at the Casualty or Emergency department. Patients rely on information provided by key accompanying person(s).

Intensive Care Unit Admit as inpatient?

4 V V Yes

Transfer to inpatient ward

CONCL USdON:

This hospital offers a unique setting among the public hospitals due to the

following factors: a) it is administered directly by the Ministry of Health,

Government of India, with service terms and conditions different from

individual state-run hospitals. Doctors here do not take up private practice

and all services delivered can be directly and completely attributed to the

hospital setting. b) it is a teaching hospital offering undergraduate and

postgraduate programs and hospital services are a part of the training and

research activities. c) although a referral hospital, due to lack of adequate

facilities in the surrounding area, the hospital treats routine as well as

referred patients with differing illness severity. The same reason makes

this hospital fairly representative of the patient population of the

neighbouring Tamil Nadu State and of parts of South India.

The inpatient population has been chosen for this study, patients being

derived from most of the clinical service departments of the hospital to

ensure representativeness of views.